Ep. 11: Nutrition Practices in the NICU—Perspectives from Dr. Corrine Hanson

Dr. Corrine Hanson

Dr. Corrine Hanson. Photo courtesy of Dr. Corrine Hanson.

Episode 11 features Dr. Corrine Hanson, Associate Professor in the Division of Medical Nutrition Education, College of Allied Health Professions, University of Nebraska Medical Center (Omaha, NE). Dr. Hanson provides a comprehensive overview of standardized feeding protocols as they apply primarily to very low birth weight babies, those weighing less than 1500 grams (3 pounds 4.91 ounces) and who have the greatest risk for developing the NEC. She discusses:

* The unique nutritional needs of very low birth weight babies

* The importance, and inherent challenges, of initiating the feeding of premature babies

* What constitutes standardized feeding protocols

* How standardized feeding protocols appear to decrease rates of NEC and improve outcomes

* Nutritional support related to a secondary diagnosis of Short Bowel Syndrome.

Copyright © 2016 The Morgan Leary Vaughan Fund, Inc. This episode was produced in part by the TeacherCast Educational Broadcasting Network.

STEPHANIE VAUGHAN, HOST: Welcome to Episode 11 of Speaking of NEC—a free, audio podcast series about Necrotizing Enterocolitis.

Produced by The Morgan Leary Vaughan Fund, and funded by The Petit Family FoundationSpeaking of NEC is a series of one-on-one conversations with relevant NEC experts—neonatologists, clinicians and researchers—that highlights current prevention, diagnosis, and treatment strategies for NEC, and the search for a cure.

For more information about this podcast series or The Morgan Leary Vaughan Fund, visit our website at morgansfund.org.

Hello, my name is Stephanie Vaughan. Welcome to the show. I’m the Co-founder and President of The Morgan Leary Vaughan Fund.

Today, my guest will be Dr. Corrine Hanson, Associate Professor in the Division of Medical Nutrition Education, College of Allied Health Professions, University of Nebraska Medical Center in Omaha, Nebraska.

Dr. Hanson will share with me today a comprehensive overview of standardized feeding protocols as they apply primarily to very low birth weight babies, those weighing less than 1500 grams or 3 pounds 4.91 ounces and who have the greatest risk for developing the NEC.

During our conversation, she will discuss in varying degrees:

  • The unique nutritional needs of very low birth weight babies
  • The benefits and risks associated with initiating feedings
  • What constitutes a standardized feeding protocol, and
  • How they appear to decrease rates of NEC and improve outcomes.

She will also discuss the nutritional concerns, and support, of a premature baby with a secondary diagnosis of Short Bowel Syndrome.

With that in mind, let me introduce my guest today.

Hi, I’m here with Dr. Corrine Hanson. Hi, Corri, how are you?

DR. CORRINE HANSON, GUEST: Hi, I’m fine, how are you?

STEPHANIE: Good, I want to give you a minute to introduce yourself and share a little bit of your background.

DR. HANSON: Okay, well, thank you. I am a registered dietitian by training, and I spent many, many years of my career working as a dietitian in the neonatal intensive care unit where I was responsible for the nutrition management of all sort of NICU related issues, whether that be prematurity, very low birth weight infants, or maybe a baby who was born with a special disease state and needed to come to the NICU for the management of that. While I worked in the NICU, I was really, really interested in our outcomes of our nutrition policies or changes that we were making in nutrition management. And so I really liked to collect data on those and see how we were doing and try and analyze our outcomes. And so, that kind of led me down a path of research. Once I started doing that, I realized that I really, really liked doing that. And so then went back to school and got my doctorate in nutrition and clinical and translational research. And ever since then, have continued to search in the NICU population.

STEPHANIE: Oh, that’s great! So what can you tell me sort of from the parent’s perspective of what a typical nutrition protocol would be for a baby in the NICU?

DR. HANSON: Well, we hope to see them early, so it’s going to depend. It’s going to completely vary depending. It depends on their gestational age, it depends on their weight, and it depends on if they’re there for prematurity or if they’re there for management of some other disease. Maybe a baby’s this or an inborn error of metabolism that will come back to the NICU. But let’s take a premature infant who has very low birth weight, and so maybe somebody, a lot of times, one of the things that we’ll talk about today which is standardized feeding protocols apply to babies who are born with a birth weight less than 1500 grams (3 pounds 4.91 ounces) and so there are several things that we want to do for that baby. Premature babies, a premature baby of that size has about the highest nutritional needs of any population that you will ever work with. Per kilo, they need more calories, they need more protein, they need more of all of the vitamins and minerals. For example, when you’re born, before the third trimester of pregnancy, you haven’t had time to mineralize your bones yet. So basically, you’re born without bones. And so we need to get you something like three times the amount of calcium and phosphorous that we would give to a term baby, because not only do we need to meet your baseline needs for those, now we need to give you enough to lay down bones. So we have a very unique challenge getting the nutrition that a premature baby needs delivered to them, because we’re dealing now with a little tiny GI tract, a little tiny gut that’s just not quite done yet. And so it can be very, very difficult to feed. And we’re watching for things like feeding intolerance and things like necrotizing enterocolitis and trying to give this new bowel and gut that’s not quite done yet a chance to mature and grow and be able to absorb and metabolize the nutrients. So we would hope‚—we really, really like to get a baby that’s born that small some form of nutrition up and running as soon as possible after birth, and a lot of times, that’s in the form of nutrition in their IV. So it’s going to be some, they have several different lines, and so in those lines, we’re going to be running protein, we’re going to be running some dextrose and some electrolytes and nutrients, and we want that to start as soon as possible. And then hopefully, we start feeding the gut as early as we feel like it’s safe after the baby’s born. If you don’t use it, things can get worse. Things can kind of start to atrophy, you know, use it or lose it. The gut is an organ that that totally applies to. And so we do want to feed it as soon as possible after birth, but on the other hand, we do need to be very, very careful. And so there are, we start feedings very small, small amounts, and we will advance them very, very slowly to what we call full feedings, or the point where all of their nutrients are being provided to them via their gut, and there are going to be several steps in that process. The amount that they’re getting into their gut will go up, the IV fluids will go down, and if they are receiving mom’s breast milk, which is what we want them to get, that is the perfect food for all babies, including premature babies, but eventually we might have to add a fortifier to that. It just adds some extra protein, and extra things like that, that extra calcium and phosphorus that I was talking about that premature babies just have such high needs for.

STEPHANIE: Okay, and speaking of NEC, is there any particular protocol or anything that you would do differently when there is a concern for that? Or I guess can you explain what the standardized protocol would be in terms of prevention?

DR. HANSON: Sure, yes, so of course, you’re always worried about NEC when an infant is born prematurely. And babies are usually fed before they get NEC. So once we start feeding babies, we are very, very aware that that’s possible that that can happen. But we also are worried about getting that nutrition in. The fear of NEC in the NICU can lead to wide variations in practice. It can lead to very cautious feeding, and it can lead to delays in starting feeding, and these things can cause what we call growth restriction, or very slow growth in a baby, and that’s associated with its own set of consequences as well. That’s associated with a delayed neurodevelopmental outcomes later in life, and things like that that we don’t want to happen. So we really are walking a tightrope here. So a lot of times in our NEC prevention strategies, the first thing that we will do is really, really encourage moms to provide human milk‚—we want this baby to get mom’s own milk. If that’s not possible for some reason, then we might consider using donor milk in a baby for the food that we start. And then what we’re going to do is we’re going to start feedings at a certain amount‚—we start little feedings‚—we call them tropic feeds. Because the point of these feedings is not to provide the nutrition that the baby needs‚—the point of them is to be tropic to the GI tract, to stimulate the GI tract to help it mature, to help it grow up so to speak, remind it what it’s supposed to do. And then we’re going to, after a set amount of time, usually it’s somewhere in the ballpark of three to seven days, we’ll advance those feedings just a little bit every day. And a lot of times, we take those guidelines, and we put them down basically on paper in an outline form, or in the ? form of a procedure where we say consider starting feeds on this day of life at this volume. And then after, leave it there for so many days, and then after so many days, advance by this much per day, and it’s just an outline, it tells you in a step by step format what your next step needs to be and gives you guidance on when you should be doing those things and how to go about them. And we call that a standardized feeding protocol, because what we’re trying to do is decrease that variability and practice between all of the different babies. And there are a lot of things that we address in those standardized feeding protocols. We would probably want them to tell us when to start feedings, what to feed the baby, how to progress the feeds, when to get to the point where we’re going to fortify‚—add the fortifier to those feeds‚—and then we also want our feeding protocols to be able to tell us like what is our definition of feeding intolerance? What are we watching for to make sure that the baby is handling this okay, and when do we stop, when do we slow the feeds? After we stop the feeds, when do we restart them? That kind of thing. There seem to be many, many benefits to these standardized feeding protocols. And the one probably of most interest here is that they do appear to decrease rates of necrotizing enterocolitis.

STEPHANIE: That’s great, my son was, I had twins born at 28 weeks, one day. They were about two and a half pounds each. And one developed NEC during his second trophic feed, or I won’t say during, but that’s when they caught it. He had surgery and lost about 20 percent of his small intestine.

DR. HANSON: Wow.

STEPHANIE: He’s doing great now, but his brother never developed it. I think the rigidity of the double checking and all the things that came with his hands-on care when they started the feeding probably saved his life.

DR. HANSON: Oh, that’s great!

STEPHANIE: So that’s how we started this, and that’s how we started this podcast as well to sort of get all of this information out to parents, because it was so early on in our NICU stay that I don’t think we had really any knowledge of much of anything that was going on. We were still recovering from their birth. He was four days old when this happened.

DR. HANSON: Oh, my gosh!

STEPHANIE: So it was sort of after the fact.

DR. HANSON: Oh, there is so much for a parent in the NICU to absorb. The shock of all this, and the trauma and you’re scared, and NICU is not an environment that is familiar to very many people, so every word is new. Everything is new. And so certainly the last thing on your mind is standardized feeding protocols. Why on earth would you be thinking or learning or reading about standardized feeding protocols there? That would just be so low on your list. And even the title of it sounds pretty boring and inconsequential. So why would I even be interested in that? So I don’t know that parents necessarily get the education that we have a plan here and we’re doing what we do for a reason. And we’re following‚—we follow this plan for a reason. We’ve based it on the evidence to the extent that we have evidence. That’s what we base standardized feeding protocols on. The really interesting thing when I think about standardized feeding protocols is that people have studied them in the literature over and over and over, and they’re usually associated with improvements and outcomes. Not necessarily the same outcomes. People will look at reduction in NEC, they’ll also look at days that it takes to advance to full feeds. Days that the babies are NPO, which means that they’re not getting any food in their gut whatsoever. Maybe the days that they have a central line, which is a risk for infection. And those outcomes differ, too, depending on what they’re looking at and what kind of data they collected. But the thing that’s interesting about it is that pretty much, the protocol that places implement are usually different. No two institutions necessarily come up with the same protocol. But we all see improvements in outcomes when we implement a standardized feeding protocol. So we really believe that it’s the reduction in variability in practice that’s important, not necessarily what you do exactly. It’s that now you’ve reduced variability across your unit, and you’re thinking about these things and you have a plan and you have a systematic approach to the way that you’re feeding babies. You don’t have to get as stressed about did we do exactly the right thing in our standardized feeding protocol, because just by having one, you’ve done the right thing

STEPHANIE: That’s interesting. So, with the variability across NICUs or across institutions, is there sort of a high level where people are looking to develop these protocols? I know they can vary from institution to institution, but there is sort of one set of practices that are ideal or recommended?

DR. HANSON: I think that as long as your feeding protocol addresses the things that I listed earlier, you know? You can certainly tailor it to your unit and to the way, what works best for your unit, your nursing staff, and what your neonatologists are comfortable with, I think as long as it addresses the things like when to start feedings, what to feed, progressing the feeds, fortifying, maybe some criteria, some guidance on when to stop them, when to restart them‚—I think as long as you address those things, then you’ve pretty much got it covered. I don’t know right now that nationwide people are looking to develop the perfect protocol. I think right now what we’re trying to do is just kind of get the word out there that you need to develop a protocol. And here is a whole bunch of examples. Here is what other people have done, take it and tailor it to what works for you, but get something in place. Right now, the most current surveys that we have are really that only about 26% of NICUs follow standardized feeding protocols. Hopefully that’s going up. That’s several years old, that number is several years old, so hopefully it’s much, much higher now, thanks to things like your podcast and hopefully the work that we’re publishing hopefully we’re getting the word out there, and more and more units are doing it now. Fingers crossed.

STEPHANIE: Right. So then I have another question. One of the major complications from NEC obviously is short bowel syndrome, or short gut syndrome. If that were to be the case, what would standardized feeding protocols, or in your experience, dietary concerns be for babies in that situation? And sort of, what can parents look for when the baby’s transitioning home?

DR. HANSON: Well, that is going to vary from baby to baby a huge amount, because it depends on so many different things. There are babies that might have NEC and might go have a bowel resection that do absolutely fine and have no issues with that whatsoever. It just depends on where the bowel resection was, and how much of the bowel was taken. So if you just had a little small amount taken, then your GI tract eventually can recover from that, and you’re going to be okay. Once you start getting into bigger resections or one thing we really are interested in is whether or not you kept the ileocecal valve, which is kind of the dividing line between the colon and the ileum. That can make a difference in how well you’re going to handle your food and things like that. But if you have NEC and you have a fairly good sized resection, you might be dealing with short bowel syndrome on the long term. So this would be something where parents can probably expect to have a pretty frequent follow up with either the NICU follow up team, or possibly a gastroenterologist. And they probably will have longer term contact with a dietitian here. We need to make sure that this baby grows. That’s going to be the number one thing on our mind. And if we can’t get enough food in in the GI tract, we will try different variations of things to see what the baby tolerates. They may or may not handle intact formula. And that’s where the protein is all intact and not broken down. Obviously, again, we still want breast milk for these babies. That’s best for these babies, certainly babies even with short bowel syndrome handle breast milk the best. But maybe the baby won’t handle the fortifier now very well, but we do need to get some added nutrients in. We will be looking at some special other ways of getting some additional micro nutrients or even calories in to make sure that the baby grows. We may have to look at still supplemental IV feedings. So it’s possible that a baby could go home with a line, and continue to receive parenteral nutrition, which is the nutrition going into a vein to just make sure that they’re getting adequate calories and protein and everything that they need to grow. Growth is going to be our very, very first concern, making sure that those needs are met. After that, we’re going to start looking at micronutrients, and again, if we can’t get enough of those in in food because the baby just doesn’t tolerate it, a baby with short bowel syndrome might have problems with just lots and lots of diarrhea and stools or vomiting, or they just don’t have‚—maybe they just don’t have enough gut‚—you absorb everything through your gut, and it’s dependent on surface area. So when your bowels are resected and you’ve lost a lot of surface area, you’ve just decreased the amount of time that nutrients can be absorbed, and if your bowel is too short, you just don’t have enough time to get all of them. So we’ll be looking at things like absorption. We might monitor serum levels of nutrients to make sure that enough of them is being absorbed to meet the baby’s needs. Then also, if the baby does need parenteral nutrition as a supplement to whatever we’re trying to feed them in their gut, we’ll try to use the gut. Again, it’s that tropic effect of feeding. It’s really important to keep using it. So even if we can only use it a little bit, we will, and then if the baby is getting some sort of supplemental nutrition through an IV or a line, that has its own set of risks, and one of those risks can be liver disease. And so then we might be watching for signs and symptoms of liver disease and making adjustments as we need to in the IV nutrition to help minimize those risks.

STEPHANIE: Okay. Yeah, I mean, it seems to be from what I’m learning that it can be a very long term process.

DR. HANSON: It can be lifelong‚—in some people it can be lifelong.

STEPHANIE: Right.

DR. HANSON: And so we do want to be very, very careful with how we feed, because things like parenteral nutrition where we feed you through a vein, that can keep you alive, but it can also be not good for you. So we have to do it right. So we’re really, really being careful to make sure and try and do all of these‚—this big balancing act of using the GI tract as much as we can, yet getting everything in that needs to go in so that we have normal growth and development.

STEPHANIE: Great, is there anything else that you would want to communicate to parents that are listening or other clinicians with regard to prematurity and/or NEC and dietary concerns?

DR. HANSON: I think I would just tell parents to ask a lot of questions if they have them. Like I said, you’re learning so much, and this is such a scary time. But nutrition is one of the key things for a premature baby. And so keep it in the back of your mind, ask a lot of questions about it, get informed and find out what you can do to help your baby with their nutrition. Certainly providing breast milk is going to be something that you can do that will improve your baby’s nutrition. Some things like even the skin-to-skin contact, those babies, some studies show that those babies should get the skin-to-skin contact. They will handle their feedings a little bit better. So I think, be aware of what the plan is, and find out what can I do to make sure that my baby can get the best nutrition possible. And I think I would say the clinicians, that it is a balancing act, and we all are very, very afraid of NEC. But we can’t be paralyzed by that fear and not feed babies, we’ve just got to decide what the safest way to do it is

STEPHANIE: Excellent. Well, thank you so much for joining me today. This was really interesting. This is another piece of the puzzle, like I said, as I’m doing these podcasts and learning more, it’s like all the little pieces fit together, and this is definitely something that I didn’t know too much about.

DR. HANSON: And you are fascinated with it, I’m sure.

STEPHANIE: Actually, every time we have one of these calls, I learn a little bit more and a little bit more, and it’s like I try to piece it together what happened in our situation. Or, if‚—it won’t‚—but if it were to happen again, what advice I would give to somebody so that they’re informed.

DR. HANSON: I think that’s really big.

STEPHANIE: All right, well, thank you so much. And we will talk to you again soon.

DR. HANSON: Thank you so much. Have a good day!

For more information about Dr. Hanson and her research, visit: unmc.edu. A direct link can also be found in this episode’s show notes: http://www.unmc.edu/alliedhealth/faculty/hanson.html

In closing, I’d like to share a few thoughts about today’s conversation with Dr. Hanson.

In the last couple weeks leading up to Morgan’s reconnection surgery, we had what I can only describe as quite a feeding scare.

By this point, I had returned to work while we waited for each of our boys to be discharged from their respective hospitals. During one of my daily morning calls to both NICUs, the nurse told me that the possibility of restarting Morgan’s feedings had been discussed during the morning’s rounds. She mentioned a note in his chart, and used the phrase “developmentally appropriate.”

It had always been my understanding from the surgeon that they would not restart Morgan’s until after his reconnection surgery, which had yet to be scheduled. I immediately asked if the surgeon was aware of this possible change, and if he had given his permission. It appeared that he had not yet been made aware nor had he given permission. I was adamant that no one attempt any feedings without the express consent of Morgan’s surgeon. I was afraid that restarting Morgan’s feedings without the surgeon’s knowledge could not only jeopardize his upcoming surgery, but more importantly, his health.

Being back at work only added to my anxiety while I spent the next several hours trying to reach Morgan’s surgeon and/or someone “in charge” who could definitively tell me whether or not they were going to restart feedings. Eventually (a good 5 or 6 hours later), Morgan’s surgeon called me. He confirmed that Morgan had not been fed, and that they would not restart feedings until after his surgery.

I never found out who made the initial comment about possibly restarting feedings, but our little feeding scare highlights the importance of clear communication among all NICU staff, and with parents. It’s also a good reminder for parents about being aware of the plan that is in place with regard to feeding your baby; being aware of, and understanding, all aspects of your baby’s care plan; and the importance of asking questions and advocating for your baby.

Show your support for our smallest and most fragile babies, those who have the greatest risk for developing NEC. Show your support for continued research in NEC. And join our effort to raise awareness about, and funds for research in NEC by making a donation to Morgan’s Fund at morgansfund.org/donate.

If you’ve had a personal experience with NEC and would like to share your story, or have a question or topic that you’d like to hear addressed on our show, e-mail us at feedback@morgansfund.org. We’d love to hear from you!

Copyright © 2016 The Morgan Leary Vaughan Fund, Inc.

The opinions expressed in Speaking of NEC: Necrotizing Enterocolitis (the Podcast series) and by The Morgan Leary Vaughan Fund are published for educational and informational purposes only, and are not intended as a diagnosis, treatment or as a substitute for professional medical advice, diagnosis and treatment. Please consult a local physician or other health care professional for your specific health care and/or medical needs or concerns.

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